Gynae Flashcards
Discuss ovarian torsion
Twisting of the ovary and fallopian tube on the axis between the uteroovarian and infundibuolopelvic ligaments
Commonly both structures are implicated
In ovarian torsion venous and lymphatic obstruction occurs initially with subsequent congestion and oedema of the ovary progressing to ischemia and necrosis
Due to the dual blood supply of the ovary from the uterine and ovarian arteries complete arterial obstruction is rare.
Can occur at any age but is most common in the reproductive years, becuase of the regular development of corpus luteal cysts
Most cases of torsion occur due to enlarged ovaries with sizes greater than 5cm being at risk of torsion. Benign neoplasm, cysts, hyperstimulation syndrome, PCOS all increase the risk of Torsion.
Discuss clinical features of torsion
Severe sharp unilateral lower abdominal pain and nausea.
Despite adequate imaging the pre-operative diagnosis rate only approaches 40%
Patient typically report pain for hours to days at presentation
Unilateral tenderness on abdominal palpation
Discuss IX of ovarian torsion
Bloods – nil specific, should have Bhcg abd G&H
US - primary modality of IX,
- enlargement of one ovary with a heterogeneous stroma secondary to oedema along with small peripherally displaced follicles is the classic US appearance.
- May reveal a mass in the ovary evidence of hemorrhage or free pelvic fluid
- doppler finding are inconsistent for diagnosis torsion, up to 60% of surgically proven torsion will have document blood flow on doppler examination.
- Despite the limitation to dopple finding of abnormal venous flow is suggestive of early torsion,
- Absent arterial flow is highly specific for torsion with PPV of 94% to 100%
- Visualisation of the twisting of the pedicle and coiled vessels is referred to as a whirlpool sign and has a 90% PPV for torsion
CT- if diagnosis is in doubt good for other DDX finding include
- enlargement of ovary
- associated mass
- thickening of the fallopian tube
- free pelvic fluid
- edema of the ovary
- deviation of the uterues to the affect side
- associated hemorrhage
MRI- Good
Laproscopy - gold standard investigative modality in who clinical suspicion is high
Discuss management and disposition of ovarian torsion
Once diagnosis made patient should be taken to OT as soon as possible
The ovary will often recover, even if black or dusky in appearance at time of surgery
Discuss ovarian cysts
Most common cause of gynaecological masses. They occur at any stage of life but are most frequent in the reproductive years due to cyclic changes in the ovary
Most cysts in the premenopausal and postmenopausal region resolve spontaneously - on occasion they be malignant or be complicated with haemorrhage or torsion
The most common type of cyst is a simple follicular cyst or functional cyst
The most common presentation is pelvic pain
- ruptured follicular cyst may produce transiet pelvic pain and by associated with dyspareunia - due to its thin wall it may rupture during sex or during vaginal examination
- corpus luteal cyst range from asymptomatic to chronic dull pain to acute severe pain. They can frequently be assoicated with significant degree of haemorrhage
Discuss IX of ovarian cysts
Lab tests - Bhcg, FBC for HB and haemotocrit specifically if luteal cyst rupture is considered, Ca125 for ovarina ca
US-
CT if diagnosis is unclear
Discuss the normal menstrual cycle
The menstrual cycle begins on the first day of menses. During the first part of the cycle the endometrium thickens under the influence of oestrogen and a dominant follicle develops releasing an ovum at the midpoint in the cycle.
After ovulation the ltueal phase begins characterized by the production of progesterone from the corpus luteum. This matures the lining of the uterus and if implantation does not occur the corpus luteam dies accompanied by a sharp drop in progesterone and eostrogen levels.
These changes are typically follwed by mensturation
Discuss clinical features of abnormaul uterine bleeding
Vaginal bleeding before the age of menarche is abnormal and may be the result of infection, trauma including sexual abuse or a foreign body, and structural lesions.
Women of reproductive age abnormal uterien bleeding includes a change in the frequency, duration and amount of bleeding or bleeding between menstrual cycles.
Any bleeding 12 months after a menapause is abnormal
Discuss DDX of abnormal uterine bleeding
Structural (PALM)
- polyps
- adenomyosis
- leiomyoma
- Malignancy and hyperplasia
Non-sturctural (COEIN)
- Coaguloapthy (von willibrand and all other)
- Ovulatory dysfunction
- Endometrial
- –any disruption to the hypothalamus-pituitary-ovarian pathway including (PCOS, anorexia nervosa, hyperprolactineameia and primary pituitary disease)
- Iatrogenic
- Not yet classified
Discuss management of abnormal uterine bleeding
NSAIDS are generally effective for the relief of associated cramping pain.
Anovuolatory bleeding —> OCP is effect to help regulate the cycle
Oral TXA can help mange excessive bleeding at a dose of 1.3G TDS for 5 days
Discuss emergency contraception
1.5mg or 2 doses of 0.75mg levonorgestrel and combined OCP
labled for use up to 72 hours after intercourse
Discuss bimanual examination
The index and middle fingers of the dominant hand are used to examine the vagina, cervix uterus and pelvic floor. Only a single finger can be inserted comfortably in patients with a narrow introitus.
The abdominal hand should be used to sweep the pelvic organs downward while the vaginal hand is simultaneously elevating them
The uterus is assess for
- size
- shape
- symmetry
- mobility
- position
- —axial: the axis of the uterus is the same as the vaginal axis
- —Version – postion of the entire uterus relative to the axis of the vagina (ante or retro)
- –Flexion - position of the uterine fundus relative to the axis of the cervix
- consistency
The adenxa areas are checkde for the presence of appriprately sixed mobile ovaries - palpable ovaries in postmenopausal pateints are not normal
Discuss vaginitis
General term for disorders of the vagina caused by infection, inflammation or changes in the normal vaginal flora
Symptoms include discharge, odor, pruritis and or discomfort
If discharge is present the three most common vaginal infections are
1) Bacterial vaginosis - malodoruous thing grey discharge
- –treat with metronidazole 500mg BD for 7 days, improved cure rates compared to 2gram once off dose
- – most common bacteria are gardnerella vaginalis, prevotella species, bacteroides, peptostreptococcus
2) Vaginal candidiasis - scant dsicharge that is thick white odorless and often curd like
- —-Miconazole
3) Trichomoniasis - purulent malodorous discharge accompanied by burning pruritis dysuria and frequency
- —- treat with metronidazole 500mg BD for 7 days, improved cure rates compared to 2gram once off dose
Vulvovaginal atrophy – lack of oestrogen
Describe the bartholin glands
Are the female homologue of the bulourethral glands. There main function is to secrete mucous to provide vaginal and vulvar lubciration
Each gland is approximatley 0.5cm in size and drains tiny drops of mucous into a duct 2.5cm long
The glands are deep to the posterior aspects of the labia majora
Discuss masses associated with the bartholin gland
Bartholin cyst – if the orifice to the bartholin duct becomes obstructed the mucous produced by the gland accumulates leading to cystic dilation procimal to the obstruction. - Cyst are usually sterile
Bartholin abcess- an obstructed dcut can become infected and form an abscess. The most common pathogen is E.coli, STI used to be identified in as many as one third of patients but this proportion has been declining. Other bacteria include (S. aureas, GBS, enterococcus)
Bartholin benign tumour - benign tumors of the bartholing gland are even rare than carcinoma
Bartholin gland carcinoma – rare accounting for 0.1 to 5% of vulvar malignancies
Discuss clinical presentation of bartholin gland pathology
Cysts are typically painless and may be asymptomatic – may be detected during a routine pelvic examination – larger cyst may cause discomfort typically during sexual intercours, sitting or ambulating
Abcess – typically present with severe pain and swelling patient find it difficult or impossible to walk sit or have intercourse
Discuss management of bartholin cyst
Large mass >3cm should undergo I&D to allow evacuation of the mass regardless of whether it is a cyst or abscess.
- This is usually combined with additional methods to allow continued drainage of abscess or cyst contents and to decrease risk of rcurrence
- Most patient are treated with Word Catheter rather than marsupialization
Small mass <3cm - I&D if abcess but not for small cysts
No benefit to antibiotic treatment
Define dysmenorrhea
Painful menstruation -
Can be primary process or secondary to other pelvic pathology
Primary – refers to recurrent crampy lower abdominal pain that occurs during menses in the absence of demonstrable disease that could account for the symptoms
Secondary - same pain and symptoma but occurs in women with a disorder that could account for their symptoms such as endometriosis, adenomyosis or uterine firboids
Give DDX of secondary dysmenorrhage
Gynae
- Endometriosis
- Adenomyosis
- fibroids
- ovarian cysts
- intrauterine or pelvic adhesions
- chornic PID
- obstructive endometrial polyps
- congenital obsturcrtive mullerian malformations
- cervical stenosis
- use of intrauterine contraceptive device
- pelvic congestion syndrome
- haemoatometra
Non gynae
- IBD
- IBS
- Uteropelvic junction obstruction
- psychogenic disorders
Discuss management of dysmenorrhea
General management include patient education and reassurance
NSAIDS + acetaminophen +- OCP
Mefenamic acid may be superior for dysmenorrhoea than ibuprofen by itself 250mg QID
Discuss endometriosis and its risk factors
Define as endometral glands and stroma that occurs outside of the the uterine cavity
Typically located in the pelvis but can occur at mulitple sites including the bowel diaphragm and pleural cavity
10% of reproductive age women suffer with endometriosis
Risk factors for the development of endometriosis include
- prolonged exposure to endogenous oestorgen ( menarache before age 11-13 or late menopause)
- short menstural cycle
- heavy menstural bleeding
- obstruction of menstrual outflow
Discuss clinical presentation of endometriosis
Classically present during their reproductive years with pelvic pain, infertility or and ovarian mass. + menohrragia
- Women with peritoneal or deeply infilitrating endometriosis often present with dyspareunia-
- bladder endometriosis typically present with frequency urgency and dysuria
- bowel involvement can lead to diarrhoea, constipation, dyschezia and bowel cramping
- thoracic endometriosis can present with chest pain, pneumothorax or haemothorax, haemopthysis or scapular or neck pain
Same management as dysmenorrhea as is a cause of the same
Discuss indication for surgical exploration of endometriosis
Persistant pelvic pain that does not respond to medical therapy
evalaution of severe sympotms that limit funciton
Treatment of anatomic abnormalities such as bladder lesions
Discuss ovarian hyperstimulation syndomre and its risk factors
Most serious complications of controlled ovarian hyperstimulation for assisted reproduction technologies.
It occurs when the ovaries are hyperstimulated and enlarged due to fertility treatments resulting in the shift of serum from the intravascular space to the third space mainly to the abdominal cavity - in its most severe form it is life threatening as it can cause venous or artieral thromboembolic events
Risk factors
- Previous episode of OHSS
-PCOS
-
Discuss clinical manifestation of ovarian hyperstimulation syndrome
Mild - bilatearl ovarain enlargement with multiple follicular and corpus luteum cyst, abdominal distension and discomfort , mild nausea and less frequently vomiting and diarrhea
Moderate - Those seen in mild + ultrasonic ascites - sudden increaqse in weight more than 3 kg may be an early sign
Severe - mild and moderate finding + clinical ascites and severe abdominal pain and in some patient pleural effusions
- hypovolaemia, oliguria or anuria and intractable nausea or vomtiign are frequently present.
- AKI
- Haematocrit >55% –> signfiicant haemoconcentration placing patient at risk of thromboembolism
- Electrolyte disturbance - hyponatraemia and hyperkalaemia
Critical OHSS –> Vital organ and system is seriosly comprmoised
- ARF with anuria
- cardiac arryhtmias
- respiratory insuffeiency
- DIC
